SA Sx - Esophagus 1

drraythe's version from 2017-09-13 20:21


Question Answer
#1 problem of the esophagus?FB
Why might esophagi be more prone to strictures?Poor blood supply & thoracic portion doesnt have a serosa
In short, what is Cricopharyngeal achalasia?Lack of synchrony of pharynx mm, when bolus reaches UES & part of bolus goes into esophagus & not good peristalsis
Perforation/fistula of the eso usually happens where?Usually occur in the thorax >> pleuritis fistula adheres the lungs & czs a bronchoesophageal fistula >> swallow & cough every time
#1 CS w/ eso problems?Regurgitation!!
How can you tell if something is regurg vs vomited?Regurg = non-digested food. Vomit - will have some bile & be digested (ask for a sample from the client)
CS of eso Dz?(5)Regurgitation
Why dyspnea w/ eso probs?Coughing when the PTx has aspirated regurg/vomit & it goes into the lungs & czs inflammation >> dyspnea
What is salivation due to eso probs usually like?Usually thick/hanging from the lips
When is ultrasound useful to see eso probs, when is it not?Not accurate in thoracic portion ok in cervical
If you which to assess peristalsis/see if theres cricopharyngeal achalasia, what can you do?FLUOROSCOPY
What is super useful for possibly removing FBs?Endoscopy
What is a Esophagotomy?Opening up the esophagus & suturing back
Esophageal resection & anastomosis (partial esophagectomy) is how useful?Not recommended bc the esophagus is not "user friendly"
Esophageal patching is most often used when...Bite wounds (weak point need to reinforce)
**What is the holding layer of the eso?SUBMUCOSA
**What are some unique anatomical things about the eso?**LACK A SEROSAL LAYER** (except for super tiny part of abdominal part), the mucosa is thick
What is the blood supply of the eso like?Submucosal plexus + segmental extrinsic vasculature
How do you want to handle the eso tissues?GENTLE!! Use stay sutures
(In general) How can you close the eso?Can do 1 layer closure or 2 layer closures
How would you do a 1 layer closure on the eso?Simple interrupted, knots tied on extraluminal surface (*encompasses all layers of the eso) [no inverting/everting - need to preserve lumen - appositional only]
How do you do a 2 layer closure on the eso?(1) Simple interrupted in mucosa & submucosa, knots tied in lumen
(2) Simple interrupted in submucosa, muscularis & adventitia (adventitia is just CT, there IS NO SEROSA so just basically muscularis in 2nd layer) [so knots on inside in 1st layer, knots on outside in 2nd layer]
What type of suture do you usually use in eso closure?Traditionally Prolene used in mucosa, but PDS® can be used
What are 3 approaches you can use for eso Sx?(1) Cervical
(2) Thoracic, cranial to heart
(3) Thoracic, caudal to heart
How/where do you open for a cervical approach to the eso? (How do you tie the arms?)Ventral midline, tie arms DOWN so they are not in Sx field
Where do you open for a Thoracic, cranial to heart approach to eso?Right lateral thoracotomy at 3rd, 4th or 5th interspace (left side has too many vessels for it to be convenient)
Where do you open for a Thoracic, caudal to heart approach to eso?Rright or left lateral thoracotomy at 10th, 11th or 12th interspace (might have to push back diaphragm a bit)
For all eso Sx, where do you put the arms?CAUDAL so not in Sx field (can crisscross arms in deep chested dogs)
When trying to get to the eso in a cervical approach, which mm must you separate? What structures must you be careful of?separate sternal thyroideous & sternalhyoideus (blunt dissection). Look out for carotid sheath & jugulars
What should the incision be like for a cervical eso approach?Dorsal recumbency, always make the incision very long & wide passing the thoracic inlet. Incision straight on the midline from the ramus (of mandible) to thoracic inlet.
How should you handle the eso?Gentle! Use stay sutures
It is common for things to get stuck at the thoracic inlet...why must you use caution if this is the case & you are trying to retrieve it?DONT ENTER INTO PLEURAL CAVITY or pneumothorax
The 3 indications for a ESOPHAGEAL RESECTION & ANASTOMOSIS?(1) Severe trauma or necrosis of esophagus
(2) Esophageal stricture > 3-5 cm in length that is not successfully treated by bouginage
(3) Esophageal neoplasia (rare in dog & cat)
ESOPHAGEAL RESECTION & ANASTOMOSIS → Up to ___of thoracic esophagus may be resected, but resection of more than ___ may require tension relieving techniques1/3, 3-5 cm
How do you go about closing up an eso resection & anastomosis?1st suture the back wall & adventitia muscularis then mucosa & submucosa then the front wall. If 1 layer - encompass all the 4 layers
What procedure is this? Eso resection & anastomosis (note how back wall is done 1st then front wall)
Would you rather have continuous or interrupted sutures in the eso?Interrupted, bc there is less overall continuous hardness. (Less chance of strictures)
**With a resection & anastomoses, you must sew the back wall & then the front wall...what risk does this carry & how do you check for this problem?You risk creating a stricture by accidentally grabbing the back wall w/ a bite of suture while sewing the front wall. So, pass a tube through eso when you're done to make sure you didnt do this
ESOPHAGEAL RESECTION & ANASTOMOSIS → 2 diff Sx techniques? (Tension relieving techniques)(1) Partial myotomy
(2) Cranial mobilization of stomach
Partial myotomy → explain when you do this & how you do thisDo for/w/ a eso resection & anastomosis (relives tension on the suture lines but doesnt compromise blood flow) → circumferential incision through longitudinal muscle layer 2-3 cm cranial & caudal to site of anastomosis (the circular mm layer is left intact!!!!)
What is the indication for esophageal patching?Reinforcement of esophagotomy or esophagectomy site
What are things you can use for esophageal patching?(1) Muscle pedicle graft (sternohyoid, sternothyroid, or diaphragm)
(2) Omentum
(3) Pericardium or gastric wall used on occasions
How would you use the omentum to make a esophagus patch?Take greater omentum from bursa (where it folds over) so take from bursal part w/o interfering w/ BV supply to stomach
When should you start feeding & how should you start feeding after eso Sx?NPO for 24 hours to 10 days, depending on condition of esophagus. If feeding per os, liquid diet for 3-5 days. Consider bypassing the eso (is gastrostomy)
Why place a thoracostomy tube & how long do you leave it in for?If you have opened the thorax, you need to put the neg pressure back & drain excess fluids. Thoracostomy tube for 24-48 hours, longer if pleuritis/mediastinitis is present (he said need 46 (or was it 4 to 6?) hours of substantial neg pressure)
Do you give PTxs ABx for post op Tx?ABx until all drains are removed, longer if Infnxn is present
What are 3 Factors Predisposing Esophagus to Rupture (just by being the eso, not even a sick eso)Lack of serosa (this is the "1° seal"), Pressure gradient across esophageal wall czd by changes in pleural pressure w/ breathing & Rapid dilatation associated w/ swallowing
CSs of eso FBs?Dysphagia
Refusal to eat (→ weight loss)
Depression & pyrexia (esp if pneumonia or perforation)
What are the 4 main locations where obstructions can happen (where FBs can get caught)Pharynx / esophagus, Thoracic inlet(#1), Base of heart, Esophageal hiatus
Radiographic findings – plain radiographs (for eso FB)Abnormal intraluminal density, Esophageal distension, Tracheal displacement, Abnormalities of mediastinum, Abnormalities of lung fields +/ - pleura
What are the diff ways the body can react to a FB?Destroy, encapsulate, or eliminate through GI
[other notes said: FB - destroy, encapsulate - or eliminated through fistulous tract. sometimes absorbed by wall of esophagus-ischemia-necrosis-hole in esophagus]
**Contrast radiographs may be used to assess integrity of esophagus before or after foreign body removal. If perforation is possible, what can you do?Instead of barium, use iodinated contrast medium
Iodinated contrast agents are ___ & can cz ___ if they get into the lungs.Hyperosmolar, pulmonary edema
You should only surgically repair esophagus if necessary. What other options are there before Sx?Non-surgical removal w/ endoscopy or use a balloon catheter to push the FB to the stomach morbidity & mortality is increased w/ esophagotomy
What are the 2 options for non-surgical procedures which are removal per os?Esophagoscopy, Balloon catheter retrieval
2 surgical options for removal of FB of eso?(1) Push foreign body into stomach, remove if necessary by gastrotomy
(2) Esophagotomy
Explain how Balloon catheter retrieval worksThe catheter is advanced beyond the foreign body, the balloon inflated & the catheter withdrawn
After non-surgical retrieval of the FB in the eso, what should you always check?After you finish always check the mucosa >> dont let a weak area go unnoticed Take a 2nd look!!
Tx of non-surgical retrieval of FBs if → no perforation (how to feed? ABx?)Soft diet, dont need ABx
Tx of non-surgical retrieval of FBs if → minor perforation (how to feed? ABx?)Gastrostomy tube feeding, ABx. Usually let it heal by 2nd intention so we by-pass the perf w/ the gastrostomy tube
Tx of non-surgical retrieval of FBs if → significant perforation (how to feed? ABx?)Thoracotomy
Thoracostomy tube
Gastrostomy tube feeding
Etiology of eso stricture?2° to inflammation & trauma
Complication of esophageal Sx
2° to gastro-esophageal reflux
Regurg vs would you tell them apart?Look for dip stick w/ urine w/ ph - if acid below 5 it came from gastric area, if high pH (more basic) then regurg
Why do you want to lavage eso after procedures?Lavage the esophagus afterwards to reduce chance of strictures & antacids >> both methods prevent GERD
ESOPHAGEAL STRICTURE → 3 diff options for Tx?(1) Bouginage or balloon dilation
(2) If a SHORT area of stricture, can do a resection & anastomosis (overlay mm or omental patch)
(3) If stricture is too long to be resected, eso reconstruction is required
How does balloon vs bougie work for eso dilation of strictures?Balloon you pass to stricture & then inflate to dilate it
Bougie you just pass repeatedly larger & larger ones until it stretches it
What is prog like after Tx of strictures w/ balloon/bougie?Prognosis guarded to fair for permanent dilation – stricture often recurs (dilate to a certain point > let it heal > come back again. need to keep repassing ones of different widths) (new tech: might be able to Tx refractory strictures w/ a stent)